On the trail of a migraine, is the posse finally catching up?

Sept. 13, 2006

Whoever said “ignorance is bliss” must have been thinking of the two elderly women overheard on an Amtrak train to Sacramento recently. It seems a mutual acquaintance of theirs suffered from migraines, a condition neither of them could comprehend in the least. One asked the other if she knew what caused it.

“I think you get it from watching too much TV,” her fellow passenger replied.

If that sounds like a lame answer, try this one from two doctors studying the illness for the Northeastern Ohio Universities College of Medicine: “Growing evidence supports the role of neurogenic peptides, such as serotonin and dopmanine, in the brain,” the duo explained in their research findings. The peptides “stimulate an inflammatory cascade with the release of endothelial cells, mast cells and platelets. This inflammation causes vasolidation and prevascular reaction.”

Well, that explains that. Sad to say, the medical journals are chalk full of this atomic babble, giving the impression that it’s the latest models of high-powered imaging equipment that’s driving the research, rather than the actual illness.

To be sure, no one really knows what causes a migraine.

The “vascular theory”, as it’s called, attributes the pain of severe headaches to blood vessels dilating in the head. That creates pressures on the nerves as blood pools inside the skull. Of course, what you might assume is a migraine can be something far more serious, such as an aneurysm, so getting a quick and accurate diagnosis is the essential first step in treating it. Emergency rooms nationwide have been issued guidelines in recent years for evaluating and treating migraines, so you should never forego the trip on the assumption that the situation isn’t serious enough to warrant that level of intervention.

Another common misconception revolves around the presence of “aura”. In order to be classified a migraine, a headache, it was thought, must be precipitated by visual irregularities, like glittering lights, which appear about twenty minutes before the pain hits. Yet, the vast majority of the 12 to 20 million migraine sufferers in the United States don’t experience aura. It’s also not uncommon for patients to contract both a tension headache (caused by a tight jaw or stiff muscles) and a vascular headache at the same time. Doctors used to tell you the symptoms had to fit one profile or the other, but that no longer turns out to be the case.

To muddy the waters even further, the wide-ranging set of accompanying symptoms from one patient to the next is about as diverse as the available treatment options. Depending on your circumstances, fast and permanent relief may well be had with a stronger pair of eyeglasses, a more ergonomic set-up at the office, eliminating a certain food from your diet, a sudden catharsis during your next counseling session, or simply by taking a walk in a park every morning.

We should all be so lucky. For those sufferers who set their calendars by the one or two-week intervals between debilitating migraine episodes, there may be no magic bullet rolling off the assembly line anytime soon. Millions of prescriptions are written each year, yet severe, recurring headaches seem to be as resilient as rust.

One of the quandaries researchers face in nailing down the cause of headache pain is the absence of any concrete pathogen to slip under the microscope. Unlike more traditional forms of healing, modern medicine was spawned on a mortuary slab, with the earliest M.D.’s wiling away countless hours dissecting cadavers. Of course, the efficacy of this approach has proven invaluable in treating multiple trauma injuries, ruptured appendixes, arterial sclerosis and little things like that. Yet the more subtle and dynamic processes of human biology aren’t so easy to pin down, even with an observatory-sized magnifying class and a nuclear accelerator. Sad to say, but chronic pain remains almost a complete mystery to the medical world.

In a typical severe headache, for instance, an acute throbbing sensation commences on one side of the head for up to 48 hours, then hops across to the other side for another 24 hours. A patient may also experience chills, sweats, blurred vision, nausea, diarrhea, tightness in the chest and/or labored breathing for several days. Add to that a bloated stomach, frequent urination, and a bad case of gas, and the idea that all this convoluted pathology can be resolved in a 15-minute doctor’s visit is slightly ludicrous.

Some practitioners claim hormone levels are the primary instigator of migraine episodes – at least, in women - while others swear that foods containing a substance known as tyramines trigger the illness. Still others cite the underlying psychological state of the patient (i.e. the hysterical woman hypothesis). Neurologist Dr. David Buchholz of Johns Hopkins University recently told National Public Radio that most migraines result from insufficient rest, drug use and bad eating habits.

In fact, the only thing everybody in the health care field can really agree on is that three times as many women suffer from migraines as men. At least 18 percent of American women, and 6 percent of men, get severe headaches on a recurring basis. Many claim the condition has been progressively degenerating since their teens.

So much for the standard treatments.

A questionnaire circulated by the National Headache Foundation in 2005 revealed that 98 percent of headache patients were dissatisfied with their medication. Interestingly, the press release accompanying the survey results happened to also mention that severe headaches may contribute to progressive brain disease. For that reason, the foundation now advises folks to consider taking one of the new preventative drugs on the market. Daytime television has been inundated with spots promoting pharmaceutical wares that claim to be exactly that bullet legions of sufferers have been waiting for. One of the more compelling of these commercials features Elisabeth Moss, the actress who played one of the President Bartlett’s daughters on the hit series The West Wing. Moss aims her Sanpuku eyes into the camera and reassures lonely sufferers that relief is just two capsules away.

As for the specter of brain disease, an article in the January 2004 issue of the Journal of the American Medical Association first reported this correlation with recurring headaches. Critics of the study, however, claimed the selection of participants may have predisposed its outcome. Specifically, a history of stroke or other serious conditions may have been responsible for the brain disorders. A short time later, however, the same researchers reported again in JAMA that they had repeated the study with more randomly chosen participants and produced practically the same findings.

If you want to get really fatalistic about the subject, the Headache Foundation provides tons of information along these lines on its website headaches.org. In particular, if you follow the “Headache Topic Sheets” link you’ll be introduced to a veritable Night Gallery of migraine types, including basilar migraines, cluster headaches, benign intracranial hypertension, cyclic migraine syndrome, analgesic rebound, ergotamine-related headaches, arteriovenous malformation and hemiplegic migraine. Naturally, each type of headache is elucidated upon in detail, so that if you didn’t have a migraine when you first logged onto the site, you’ll likely have one by the time you leave.

Fortunately, the Foundation doesn’t entirely dwell on pathology and the latest pharmaceutical drugs. A number of alternative healing modalities are reviewed in terms of the latest statistics available regarding their efficacy (and in a few cases, just as anecdotal insight). One of the more tried and proven herbal aides for migraines, according to headaches.org, is feverfew tea. The aptly-named remedy aids in the production of the chemical serontonin, one of the neurotransmitters linked to the onset of an episode. Drunk over a period of several weeks, feverfew tea has been shown in several studies to reduce the occurrence and severity of migraines.

An article in the journal Neuroscience recently reported on a new study that suggests adding magnesium to the diet can help reduce the number of attacks and their severity. Researchers found that up to half of all migraine sufferers are deficient in magnesium, and that the mineral is helpful in preventing vascular constriction. Magnesium is found in nuts, soy products, fruits and dark green leafy vegetables, among other sources.

Enter the Dragon: Chinese Medical Theory and Treatment

Chinese and other Asian medicine postulate that a migraine most likely begins in the liver when the “chi”, or electrical energy of the body, gets stuck, or “congested”.

Longtime San Francisco acupuncturist Harriet Beinfield describes it this way: “From my vantage point frequent migraines represent a liver/gall bladder disorder that results in liver chi and blood stagnation, and signals a weakness in the kidneys.”

Beinfield is co-author of Between Heaven and Earth: A guide to Chinese Medicine, one of the more popular books on acupuncture, alongside Ted Kaptchuk’s The Web that Has No Weaver. She says the congested chi generates internal heat and wind in the digestive organs, which, in turn, drive the chi upward. This has a domino effect, and the next thing that happens is that blood starts pooling inside the head. As Beinfield explains, “The saying is, where the chi goes, the blood flows.”

While most people attribute liver problems to an over-consumption of alcohol and/or narcotics, there’s actually a long list of triggers that can contribute to an attack. These include stress, thinking too much, sleep deprivation, eating fatty and fried foods, long term ingestion of medication or an over-reliance on stimulants like caffeine. Sensitivity to light is a good indicator that liver chi congestion is present. The liver itself is responsible for cleansing and tonifying the blood, so it follows that any disruption of service would impact the body at a core level.

“With congestion”, Beinfield writes, “Qi cannot move up and down properly. The warm dry Qi of the Lung and Heart cannot descend, and the cool moist Qi of the Kidney cannot rise. Sometimes this accounts for the fact that the upper body becomes overheated and dehydrated while the lower body becomes cold and waterlogged.” This latter phenomenum is commonly diagnosed by acupuncturists as a “damp spleen”, which is typically accompanied by a bloated stomach.

The stagnant water in the abdomen in time douses the “yang fire” of the kidneys. For those who remember what it was like to have a carburetor mess up in their cars, causing the engine to stall at a stop sign, that unhappy predicament is roughly analogous to liver/gall bladder disharmony. (For those who don’t drive cars, think of SF Muni on any given day.) Beinfield encourages patients to think less of the body as a compilation of separate anatomical parts and more along the lines of motion and circulation swirling around inside a single operating mechanism.

Currently practicing at a clinic in Noe Valley called Chinese Medical Works, Beinfield also expressed concern during a recent interview about the presence of excess estrogen in women on hormone replacement therapy. One of her patients on HRT, a busy downtown professional, came to see her when the migraines were striking about every 7 to 9 days. Beinfield suggested progesterone cream as an alternative to Premarin, and prescribed a variety of Chinese herbs, which in combination with diet and other lifestyle adjustments enabled her patient to eventually break the pattern of illness. Still, the recovery period took more than a year, and Beinfield continues to see her at intervals.

Like migraines, irregular menstruation and PMS are byproducts of chi congestion and may themselves contribute to the onset of headaches. In addition to applying acupuncture needle points, a prescription of herbs to dry up the dampness, move the chi and relax the gall bladder and liver represent a standard approach in Chinese medicine. For acute attacks, some practitioners will vigorously massage the back of the head, neck and shoulder blades to take the bite out of the pain.

Beinfield also notes that an old folk remedy of sticking feet and hands in hot water while applying a cold compress to the back of the neck can sometimes alleviate the pain.

In The Web that nas no Weaver, Kaptchuk discusses a lesser known element in Chinese medicine known as jing, which may also play a role in migraines and other chronic illness. If chi is the rough equivalent of electrical energy, then jing represents the charge that produces that energy in the first place, functioning similarly to a battery. Beinfield identifies jing as a sort of vital essence, perhaps like DNA. While we inherit our primary supply of it from our parents, there are herbs available that serve to replenish the source.

One of the more popular over-the-counter medicines commonly prescribed to women plagued by recurring migraines and other manifestations of liver chi stagnation is Xiao Yao Wan (pronounced show-yow-won). At some acupuncture clinics, it’s more poetically (and expensively) packaged as the Free and Easy Wanderer. This staple of Chinese medicine has been around for almost 900 years, and is readily available at most herb stores in Chinatown and on Clement Street. Although not a headache formula per se, the herbs that make up this patent remedy are said to move the chi, alleviate a damp spleen and support normal liver function. Like feverfew tea, Xiao Yao Wan is considered a preventative remedy for migraines.

To treat a migraine at the time it hits, some acupuncturists prescribe another patent formula known as Gastrodia Combination. The Chinese traditionally describe a headache not as an ache but as a head wind, so the aim of these herbs is to dispel gas from the body and relax the liver. The remedy comes in the form of the traditional black pellets or capsules, but it’s much harder to find than Xiao Yao Wan.

According to the bottle’s accompanying literature, Gastrodia Combination is also said to keep your hair from turning white.

Food for Thought

Both western and eastern experts concur that some foods trigger migraines. Thus, their removal from the diet may pre-empt the onset of headaches. Poor eating habits, or a tendency to eat the same food daily are also considered at-risk behavior that should be avoided.

Back in 1967, Dr. Hedda Hanington first reported in the British Medical Journal on the relationship between the chemical “tyramine” and migraines. Tyramines are common to foods that are aged or fermented. Cheese represents the biggest offender, with the ability to spark a migraine within hours, if not minutes of consumption. (Cottage, cream and goat cheese are exceptions.) Dr. Hanington stumbled across this tyramine connection while studying patients being treated for depression with certain drugs called monoamine oxidase (MAO) inhibitors.

Dr J. Gordon Millichap, a pediatric neurologist at Chicago’s Northwestern University Medical Center has reported that MAO inhibitors taken in chance combination with a meal of cheese can also cause an acute rise in blood pressure by releasing the neurotransmitter norepinephrine. Beer, pickled herring, chicken liver, yeast, coffee, broad bean pods, citrus, and canned figs all contain tyramines. Food-sensitive folks should also watch out for cured meats like hot dogs, salami and bacon, Monosodium Glutamate (MSG), chocolate, citrus fruits, the sugar substitute Aspartame, and wine containing sulphites.

According to Susan Dyson’s book on migraines, it’s possible to develop a sensitivity to almost any food simply by eating it too often. Like an allergy, a food sensitivity disrupts the normal digestive processes.

In his study published last year, Dr Millichap noted that vascular headaches can also result from ingesting an “excessive carbohydrate load”. Because the carbs stimulate rapid insulin secretion, the hormonal reaction sets the attack into motion. He advises patients to eat three well-balanced meals a day, stay away from peanuts, and learn not to over-indulge in food cravings, apparently a common tendency among those with dietary-related migraines. Frozen treats like ice cream can constrict blood vessels in the neck, which causes the blood vessels in the head to dilate, so those prone to migraines should be careful about what they eat.

Asian medicine, for its part sees modifications to the diet as playing a central role in overcoming any chronic illness. With regard to headaches, acupuncturists take a hard stance on the consumption of any fried or fatty foods, since the oils and other fats can irritate the gall bladder. (One notable exception is Omega-3 fatty acids.)

For some digestive ailments, cooked foods are suggested over raw (especially in winter), since the digestive system has a much harder time breaking down the uncooked material, and that weakens the liver, exacerbating any problems that may already exist. On the other hand, vegetables and fruits contain roughage (a.k.a. fiber), which helps keep the intestines unclogged and the chi moving. Apples are good for alleviating gall bladder irritation. While spicy food should be avoided, ginger root in tea or as part of a cooked dish aides in dispersing chi congestion.

Then there’s the question of caffeine. Many migraineurs routinely drink coffee at the first sign of a headache. Like ginger, the stimulant moves the chi and blood. However, Chinese medicine strongly discourages this practice, claiming patients pay too high a price for the short-term fix. Honora Lee Wolfe, who has written about chi congestion in breast disorders, insists that while caffeine may temporarily relieve the “stuck” chi, “because the Liver must be kept nourished by Blood in order for its Qi to move smoothly … the net effect is that the caffeine, by wasting the Liver Blood, leaves the Liver less able to promote free flow of the Qi.”

Ironically, the ultimate bullet that brings down the migraine headache may be a weapon we already have in our human arsenal – the power to relax. (See Sidebar.) As Dorothy found out after all her long travails in the Wizard of Oz, exonerating one’s self from enemy terrain may really be as simple as tapping your own internal resources and repeating “There’s no place like home.”

Of course, that assumes you have a home to go to.

Copyright 2006 The City Edition